Surgical Approaches to Biliary Tract Adenocarcinoma

Surgical resection for patients with intrahepatic cholangiocarcinoma (iCCA) is particularly challenging. At the 5th annual CCA Summit meeting, William R. Jarnagin, MD, FACS, provided an overview of the evolution of surgical management of iCCA.¹

For all patients with iCCA, control of liver disease is critical because it correlates with improved overall survival; however, establishing and maintaining control of intrahepatic disease poses a challenge.¹ The majority of patients are not candidates for resection, partly owing to late-stage presentation. In resectable patients, patient selection and risk stratification are important to achieve good clinical outcomes.¹ In a large cohort of patients treated at Memorial Sloan Kettering Cancer Center, a minority of patients underwent resection (n=82) and achieved superior survival outcomes compared with those who did not undergo resection (median disease-specific survival, 36 months).² Predictors of survival outcome were multifocality, regional nodal involvement, and large tumor size.² Unfortunately, recurrence is common after resection; in one report, among 318 resections performed, 73% recurrences were reported with liver involvement in 66% of cases. Recurrence pattern impacts survival; recurrence-free survival was worse for liver-only compared to extrahepatic recurrence.¹

For patients with advanced unresectable disease, prognostication, treatment allocation, and use of targeted therapies when applicable are critical. Therefore, knowledge of tumor genomic profile for every patient is imperative given the potential clinical benefit that may be derived from targeted therapies. In patients with advanced disease, systemic therapy provides limited efficacy; hepatic arterial infusion chemotherapy may offer more effective disease control.¹

In terms of future direction, some research efforts are focused on improving tumor characterization by noninvasive imaging using a quantitative radiomics approach.¹ Radiomics involves conversion of images into mineable high-dimensional data, followed by extraction and analysis of imaging features using texture analysis (measures of image heterogeneity), which is then correlated with genomic data. Quantitative imaging phenotypes defined by texture analysis have been shown to correlate with expression of specific markers of hypoxia, independently of conventional imaging features of CCA by visual assessment.³ Machine learning radiomics can reliably predict early liver recurrence after resection of iCCA.⁴

Although surgical resection has curative potential in iCCA, duration long-term cure is low due to high rate of recurrences; local-regional and systemic therapies may provide more alternatives for unresectable cases for management of recurrences.¹

Sources:

1. Jarnagin WR. Surgical approaches to biliary tract adenocarcinoma: update on the history of surgical management. Presented at: 5th Annual CCA Summit Meeting, October 19-21, 2023; Scottsdale, AZ.
2. Endo I, Gonen M, Yopp AC, et al. Intrahepatic cholangiocarcinoma: rising frequency, improved survival, and determinants of outcome after resection. Ann Surg. 2008;248(1):84-96.
3. Sadot E, Simpson AL, Do RKG, et al. Cholangiocarcinoma: correlation between molecular profiling and imaging phenotypes. PLoS One. 2015;10(7):e0132953.
4. Jolissaint JS, Wang T, Soares KC, et al. Machine learning radiomics can predict early liver recurrence after resection of intrahepatic cholangiocarcinoma. HPB (Oxford). 2022;24(8):1341-1350.